450,000 North Carolinians could lose health care subsidies

If you pay attention to the newsand since you read this wildly popular column with the fevered devotion of a tongues-speaker at a tent revival, we'll assume you doyou know that in the next week or so, the Supreme Court is going to rule in a case called King v. Burwell, and if the court finds for the plaintiffs, the Affordable Care Act, having survived an earlier court challenge and approximately 47.2 million repeal votes in the U.S. House of Representatives, might finally be fatally crippled.

This would be a crowning achievement for conservatives, who have fought Obamacare at every turn and with every dipshit legal theory they could conjure. It would be less good for the millions of people who would lose their health care when the insurance market went into a tailspin. But hey, you can't make an omelet without breaking a few eggs, right?

Except that even if the King prevails, the ACA won't be killed everywhereonly in the 34 states that declined the federal government's gentle suggestion to set up their own health insurance exchanges. In the (mostly blue) states that didn't stomp their feet and hyperventilate about how evil universal health care is, things will go on pretty much as normal. For the rest: absolute chaos.

Guess which camp North Carolina falls into.

Correct!

Not only does North Carolina not have its own exchange, but it also has a law, passed in 2013, that prevents any government agency from even thinking about setting up an exchange, because mumble mumbleObamacaremumble mumbletyranny. Which means that if the federal subsidies go down, the 458,738 North Carolinians who rely on them are straight-up fucked. That number, of course, is on top of the half-million poor North Carolinians who've already been straight-up fucked by the Legislature's refusal to expand Medicaid, bringing us to a grand total of something approaching 1 million peopleone in 10 state residentswho might be denied health care so lawmakers can go brag to their Gadsden flag-waving constituents about how they stuck it to the president.

Democracy, man. Gotta love it.

"That would be, obviously, a tragic result"

—N.C. Insurance Commissioner Wayne Goodwin

Anyway, you can see why N.C. Insurance Commissioner Wayne Goodwin is a little nervous. It's not just that those 458,738 people would lose their subsidies, it's that most of them would probably drop their insurance, leaving only the sickest (and most expensive) in the market. If we're lucky, this merely drives up costs exponentially, even for those with private insurance. If we're not, health insurers would leave the state, or at least abandon entire areas within the state.

This is what folks in the biz call a death spiral.

"That would be, obviously, a tragic result," says Goodwin, a Democrat. "The King decision, though it turns on a few words, [could have] an incredible negative impact on the health insurance market in states like North Carolina."

Well, sure. But there's also a pretty easy fix, even if Congress declines to resolve things like responsible adults (yeah, we know): The General Assembly could always enact its own state-level exchange. Except it's not as simple as that. There's no longer federal funding for such endeavors, and the Legislature, in its infinite wisdom, deep-sixed the years of preliminary work the state had done on just such an exchange before 2013.

But there's a plan B, Goodwin says: pass a law declaring healthcare.gov the state's exchange.

And even if Republicans don't want to go that route, this case was argued months ago. Surely by now they've worked out something.

Over to you, N.C. Department of Health and Human Services spokesperson Olivia James: "DHHS is closely monitoring the case of King v. Burwell and reviewing potential impacts of this complex issue."